AMERICAN ACADEMY OF PEDIATRICS
Committee on Drugs and Committee on Hospital Care
Prevention of Medication Errors* in the Pediatric Inpatient Setting
ABSTRACT. Medication errors that occur on a pediat-
ric medical/surgical inpatient care unit are usually avoid-
able. Several steps are recommended to reduce these
errors, beginning with the physician and including every
member of the health care team. Pediatricians should
help hospitals develop effective programs for safely pro-
viding treatment with medications to hospitalized chil-
dren.
H
ospitalized infants and children are subject
to the advantages and the risks of inpatient
care. Included in most medical and surgical
treatment of pediatric patients in the hospital is the
administration of medications that may be associated
with undesirable effects in addition to the therapeu-
tic effects. Adverse reactions to medications include
those that are usually unpredictable, such as idiosyn-
cratic or allergic responses, and those that are pre-
dictable and thus potentially avoidable, such as side
effects or toxic reactions that are related to the inher-
ent pharmacologic properties of the drug. In general,
the number and severity of adverse medication reac-
tions are directly related to the number of drugs
administered to hospitalized patients.1–3
In contrast to adverse drug reactions, medication
errors (as defined in the footnote that appears in the
bottom left corner of this page) occur as a result of
human mistakes or system flaws. Providing drug
treatment in the hospital setting usually requires a
series of actions performed by several individuals—
the physician, the unit clerk, the hospital pharmacist,
and the nurse. Errors are possible at any step of the
process from medication selection and ordering, or-
der transcription, drug formulation, and drug dis-
pensing to drug administration. The reported inci-
dence of errors in treatment with medications ranges
from 4% to 17% of all hospital admissions.1,2,4 An
error occurs once in every 20 orders for medications.1
Antibiotics, analgesics, and cardiovascular drugs are
most frequently associated with errors, but no single
medication accounts for more than 9% of the total.1,2,4
The most commonly reported errors include the fol-
*Medication error is any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the
control of the health care professional, patient, or consumer. Such events
may be related to professional practice, health care products, procedures,
and systems, including prescribing; order communication; product labeling,
packaging, and nomenclature; compounding; dispensing; distribution; ad-
ministration; education; monitoring; and use. United States Pharmacopoeia.
The Standard. November/December 1995:10.
The recommendations in this statement do not indicate an exclusive course
of treatment or serve as a standard of medical care. Variations, taking into
account individual circumstances, may be appropriate.
PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad-
emy of Pediatrics.
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lowing: inappropriate medication for the condition
being treated; incorrect dosage or frequency of ad-
ministration of medication; wrong route of adminis-
tration; failure to recognize drug interactions; lack of
monitoring for drug side effects; and inadequate
communication between the physician, other mem-
bers of the health care team, and the patient. Of
these, incorrect dosing is the most frequent.5,6 In
teaching hospitals, prescribing errors decrease with
each year of training; the error rate for attending
physicians, however, is exceeded only by that of
first-year residents.4 Fortunately, 75% of erroneous
medication orders are intercepted and corrected be-
fore the drugs are administered to patients.1
Medication errors produce a variety of problems,
ranging from minor discomfort to substantial mor-
bidity that may prolong hospitalization or lead to
death.1,3,7 Drug errors associated with morbidity and
mortality increase health care costs by an estimated
$1900 per patient8 and are frequent causes of litiga-
tion involving patients, families, institutions, and
physicians. In a study of medical liability suits filed
during a 7-year period, the Physician Insurers Asso-
ciation of America found in more than 90 000 mal-
practice claims that medication error was the second
most frequent cause and second most expensive ba-
sis for litigation.8 Pediatrics ranked sixth among 16
medical specialties in frequency of medication-re-
lated claims. With an average of $292 136 per case,
pediatric settlements were twice those of other spe-
cialties.
The American Academy of Pediatrics is committed
to reducing medication errors in the treatment of
children.9 Because the causes of drug errors are mul-
tifactorial, institutions caring for children must de-
velop multidisciplinary programs involving active
participation by physicians, nurses, pharmacists, and
when feasible, information system specialists to sig-
nificantly reduce medication errors. Such programs
should be an integral part of the institutional quality
assurance and quality performance activities and,
when possible, incorporate computer-assisted drug
ordering and monitoring. The Academy recognizes
and supports the extensive studies and policies de-
veloped by other organizations to reduce/eliminate
drug administration errors.10,11 The program delin-
eated by the American Society of Health-System
Pharmacists is one example of a comprehensive ap-
proach to the reduction of medication errors in hos-
pitalized patients.10 Several of their recommenda-
tions are indicated in the Appendix.
Physicians who care for children in the hospital
setting are encouraged to promote, if not actively
develop, programs to reduce medication errors in
their institutions. At the same time, it is incumbent
on hospitals to include such programs in their rules
and regulations in an effort to reduce the risk of
hospitalization and the attendant errors associated
with drug treatment.
APPENDIX
The following tables outline some of the recom-
mendations developed by various individuals and
groups to assist in reduction of drug errors6,9,10:
Hospital-wide Actions and Policies to Decrease
Medication Errors
• Establish and maintain functional formulary sys-
tem with policies for drug evaluation, selection, and
therapeutic use.
• Provide an adequate number of well-trained per-
sons to prepare, dispense, and administer medica-
tions.
• Provide a suitable work environment for safe,
effective drug preparation.
• Establish a clearly defined system for drug or-
dering, dispensing, and administration that includes
review of the original drug order before dispensing
and administration.
• Provide ongoing formal quality improvement of
the therapeutic use of medications including a drug-
use evaluation (DUE) program.
• Maintain medication profiles for both inpatients
and ambulatory patients receiving care at the hospi-
tal.
• Computerize systems, where possible, to check
dose and dosage schedules, drug interactions, aller-
gies, and duplicated therapies.
Medication Ordering to Reduce Errors
Physician prescriptions and drug orders are a
means of communicating, so they must be legible,
clear, and unambiguous. The following steps may
help to ensure that medication orders communicate
safely and effectively.
• Confirm that the patient’s weight is correct for
weight-based dosages.
• Identify drug allergies in patients.
• Write out instructions rather than using abbrevi-
ations.
• Avoid vague instructions (eg, take as directed; no
order should be written without dose and volume
where appropriate).
• Specify exact dosage strength.
• Avoid use of a terminal zero to the right of the
decimal point (eg, use 5 rather than 5.0) to minimize
10-fold dosing errors.
• Use a zero to the left of a dose less than 1 (eg, use
0.1 rather than .1) to avoid 10-fold dosing errors.
• Avoid abbreviations of drug names (eg, MS may
mean morphine sulfate or magnesium sulfate).
• Spell out dosage units rather than using abbre-
viations (eg, milligram or microgram rather than mg
or mg; units rather than u).
• Ensure that prescriptions and signatures are leg-
ible, even if it means printing the prescriber’s name
that corresponds to the signature.
Downloaded from www.aappublications.org/news at Philippines:AAP SponsoredACADEMY
Prescriber Actions to Decrease Medication Errors
• Stay current concerning appropriate treatment of
medical conditions they manage.
• Review the patient’s existing drug therapy before
prescribing new medications.
• Remain familiar with individual hospital medi-
cation ordering systems.
• Ensure that drug orders are complete, clear, un-
ambiguous, and legible.
• Reserve verbal orders for instances when it is
impossible or impractical to write an order or enter it
in the computer.
• When possible, speak with the patient or care-
giver about the medication that is prescribed and any
special precautions or observations that should be
noted, such as allergic or hypersensitivity reactions.
• Clarify orders to “hold” medications and avoid
these whenever possible.
Pharmacy Actions to Decrease Medication Errors
• Remain available to prescribers and nurses to
participate in drug therapy development and moni-
toring.
• Never guess or assume the intent of confusing
medication orders.
• Review an original copy of the written medica-
tion order before dispensing a medication, except in
emergency situations.
• Prepare drugs in a clean and orderly work area
with a minimum of interruptions.
• Dispense medication in a timely fashion using a
unit-dose, ready-to-administer form whenever pos-
sible.
• Provide counsel to patients or caregivers about
their medications.
Nurse Actions to Decrease Medication Errors
• Be familiar with medication ordering and use
system.
• Verify drug orders before medication adminis-
tration.
• Confirm patient identity before administration of
each dose.
• Check medication calculations with a second
individual.
• Unusually large volumes or dosage units for a
single patient dose should be verified.
• When a patient questions whether a drug should
be administered, the nurse should listen, answer
questions, and if appropriate, double check the med-
ication order.
• Remain familiar with the operation of medication
administration devices and the potential for errors
with such devices.
Committee on Drugs, 1996 to 1997
Cheston M. Berlin, Jr, MD, Chairperson
D. Gail McCarver, MD
Daniel A. Notterman, MD
Robert M. Ward, MD
Douglas N. Weismann, MD
Geraldine S. Wilson, MD
John T. Wilson, MD
AMERICAN
OF2019
on September 15, PEDIATRICS 429
 Liaison Representatives Paul R. VanOstenberg, DDS, MS
Donald R. Bennett MD, PhD Joint Commission on Accreditation of
American Medical Association/United States Healthcare Organizations
Pharmacopeia Robert T. Maruca
Iffath Abbasi Hoskins, MD American Hospital Association
American College of Obstetricians and Jerriann M. Wilson
Gynecologists Association for the Care of Children’s Health
Paul Kaufman, MD Section Liaison
Pharmaceutical Research and Manufacturers Theodore Striker, MD
Association of America Section on Anesthesiology
Siddika Mithani, MD
Health Protection Branch, Canada REFERENCES
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 Prevention of Medication Errors in the Pediatric Inpatient Setting
Committee on Drugs and Committee on Hospital Care
Pediatrics 1998;102;428
DOI: 10.1542/peds.102.2.428

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 Prevention of Medication Errors in the Pediatric Inpatient Setting
Committee on Drugs and Committee on Hospital Care
Pediatrics 1998;102;428
DOI: 10.1542/peds.102.2.428

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/102/2/428

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
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